This part is common to all the victims of the shooting that occurred at
the Université de Montréal École Polytechnique in
Montreal on December 6, 1989. It is an integral part of each and every
one of the investigation reports signed on this date, which are numbered
as follows:

In order to establish whether any one of the victims could have been
saved, in medical terms, having regard to the exact nature of each victim's
injuries, it is useful and even essential, in the circumstances, to consult
medical experts; here, these are the members of the post-trauma mortality
prevention committee of the Montreal General Hospital.

2.1.1 Description of work done by the comité pour la prevention
de la mortalité post-traumatique de l'Hôpital Général
de Montréal [post-trauma mortality committee of the Montreal General
Hospital]

This committee includes a cardiovascular surgeon, an emergency medicine
specialist, an anaesthetist-resuscitator, an internist and an epidemiologist.

In order to perform the specific mandate of objectively assessing the
chances of survival of each of the victims who died as a result of the
events in the shooting at the Polytechnique, having regard to the circumstances
and the injuries received by each of the victims, a two-stage assessment
method was used for this purpose.

First, all of the autopsy reports were analysed by each of the members
of the committee, individually and then as a group. Based on this review
of the files, a probability of death index was assigned to each of the
cases assessed.

Second, the survivors were compared to the victims who died, in terms
of the severity and the circumstances surrounding the injuries suffered.

2.1.1.1 First floor

The autopsy reports were studied by each member of the committee individually.
The identity of the victims and the details concerning the time when the
injuries were inflicted, as well as the exact place where each of the
victims was found, were not provided to the assessors. Each case was then
assessed by the full committee, with the same restrictions regarding the
details referred to above. In addition, each of the committee members
was not aware of the individual conclusions of the other members until
the final assessment was done. This process included an assessment of
the injuries as described in the autopsy reports and the development of
an index to measure the severity of the injuries in each case.

That index measures the severity of the injuries based on the anatomical
region of the injuries, and is a precise predictor of the rates of mortality
and disability that result. The points on the index that result in a 100%
probability of mortality mean certain death, regardless of the other circumstances.
More precisely, that means that the victim cannot survive despite receiving
the best first-line care, despite the best time being taken to administer
first-line care, despite the best time being taken before definitive care
is provided, and despite the best definitive care, that is, in a hospital
specializing in the treatment of persons with traumatic injuries. All
the cases that were given points on this index resulting in a 100% possibility
of death were considered to be closed. For the cases that were given points
resulting in a less than 100% probability of death, data such as emergency
services response time were disclosed so that they could be taken into
consideration in the final assessment. Accordingly, the possible consequences
of delay in providing care were assessed having regard to the scene of
the tragedy and the distance to hospitals that could treat these kinds
of injuries, assuming optimum response by first-line emergency services.

2.1.1.2 Second floor

The survivors of this tragedy comprised a control group: injuries inflicted
in the same way, at nearly the same time, same age category. By comparing
the severity of the injuries of the non-survivors with those of the survivors,
it is possible to validate the conclusions reached regarding probability
of death.

The study showed that all the deaths occurred by reason of the severity
of the injuries suffered and that none of the victims could have survived,
the injuries suffered by the survivors being significantly less serious
than those of the non-survivors.

2.1.2 Comments

Use of the concept of avoidable death is becoming increasingly common
in assessing the quality of care given to injured persons. In 1974, West
was one of the first researchers to use this concept to assess the impact
that emergency medicine might have on the mortality rate among injured
persons. Since then, this method of assessment has been used by a number
of researchers.

In any study of mortality prevention, the first step is to define the
concept of an injured person who can survive.

The criteria that define a death as avoidable must be established before
doing any objective assessment of the relevant data, and must not be open
to subjective interpretation. Once these criteria have been established,
the assessment of the cases based on the available data must make it possible
to classify them as avoidable, potentially avoidable or unavoidable deaths.

In this study of the cases of deaths resulting from the shooting at
the Polytechnique, the probability of death for each case was established
based on the point scale referred to earlier, "index of severity
of the injuries suffered". Since this method had already been put
to the test, it is considered to be a valid predictor of mortality rates
and the incidence of disability. While this method is not perfect, it
is the best available for assessing the severity of injuries, having regard
to the anatomical site of the injuries and the damage caused, including
where more than one anatomical region is involved. In addition, given
that the points assigned by different assessors are very similar, the
results of this study are verifiable.

2.2 CIRCUMSTANCES

In order to ensure access to all useful and relevant information for
determining the complete circumstances of this case, a large number of
documents were assembled and several people were interviewed.

That information was then examined and meticulously compared, and then
analysed. In order to establish an accurate chronological sequence of
the event, it was then necessary to juxtapose the information received
from various sources, and so, in some cases, in order to make them comparable,
the precise times of certain elements were adjusted to Ottawa's official
time.

The following is a list of the documents consulted:

- police report, together with numerous attachments;
- attachment to the police report comparing the time of the SPCUM dispatch
service recording (S.I.T.I.) and of the 9-1-1 Centre time to the Ottawa
official time;
- report of the director of the SPCUM to the chair of president of the
CUM executive committee;
- certain exhibits seized on the scene following the event, and elsewhere,
subsequently;
- forensic reports;
- ballistics and other expert reports;
- video of the scenes of the event;
- detailed plans of the scene;
- several tape recordings of Urgences-Santé communications at the
time of the event;

- videos of several televised reports and public affairs programs;
- tape recordings of several radio reports and public affairs programs;
- report of the post-trauma mortality prevention committee of the Montreal
General Hospital;
- transcripts of statements by certain persons involved in the event who
were interviewed;
- minutes of an Urgences-Santé meeting concerning the event;
- time-stamped record of 9-1-1 Centre and the SPCUM dispatch service (S.I.T.I.);
- list of police vehicles dispatched to the scene;
- compilation of calls and requests by the SPCUM dispatch service (S.I.T.I.);
- compilation of telephone calls to the SPCUM concerning the event.

2.2.1 Description of the scene

2.2.1.1 First floor

This is the cafeteria inside the school, to the left of the S-17 students'
entrance. It is also accessible through the main entrance to the school,
using door B-107.

This place has a capacity of about 400 persons, and at the time of the
incident there were about 100 there. The cafeteria includes a kitchen,
and at the end of the room there is an unlocked storage area (polyparty)
where a variety of items is stored.

2.2.1.2 Second floor

2.2.1.2.1 Room C-230.4

This room is located to the east of the escalators and at the end of the
corridor. On that day, there was a mechanical engineering class in the
room, and according to the school's computer file there could have been
69 students and 2 professors in the room.

2.2.1.2.2 Room B-218

This is the room occupied by the Polytechnique's financial services.

2.2.1.2.3 Corridor

This is the central corridor on the second floor, connecting room C-230.4
to the escalators.

2.2.1.3 Third floor

2.2.1.3.1 Room B-311

This is the room where, at the time of the incident, a materials engineering
class was being held. According to the school's computer record, there
may have been 26 students and 2 instructors.

2.2.1.3.2 Corridor

This is a third-floor corridor located near the escalators and beside
room B-311.

2.2.2 The shooting

During the day of December 6, 1989, Marc Lépine, born October
26, 1964, in Montreal, was seen for the first time in the office of the
registrar, room A-201. He was seen there between approximately 16:00 and
16:40.

He was sitting on the bench in the entrance to the room, near the door.
From that position, he was impeding access to the department, where student
traffic is heavy. He was sitting in such a way as to make it difficult
to enter the room.

On several occasions, he was seen rummaging in a green plastic bag that
he had beside him, the contents of which he seemed to be hiding. He did
not speak to anyone, and none of the students spoke to him. At one point,
one of the employees working at the counter asked him whether she could
help him. He did not answer and he left the premises.

At 16:45, Lépine was seen in a corridor on the third floor. He
was leaning on the wall, holding a black plastic bag with a long object
inside it, and a small white plastic bag. He was dressed in a pair of
blue jeans and was wearing Kodiak boots.

He was then seen in a corridor on the second floor at about 17:10.,
at which time he was heading toward room C-230.4.

At 17:10, Lépine entered room C-230.4 and moved toward a student
who was giving a presentation. Lépine was holding a rifle in both
hands. He approached the student and said: "Everybody stop everything."
He suddenly fired a shot at the ceiling and said: "Separate - the
girls on the left and the guys on the right."

No one reacted to his order. He repeated the same words in a much more
authoritarian tone. The students then separated, but in their nervousness,
the girls and boys mixed together in a group. He pointed with his right
hand to the right side of the classroom, the side near the door, and told
the boys to go over there. He then indicated with his left hand the back
left corner of the classroom, and asked the girls to go over there. After
the groups had separated, he told them: "OK, the guys leave, the
girls stay there."

They thought it was an end of session joke, and that the attacker was
firing blanks.

During this time, Lépine moved a little closer to the group of
9 girls who were standing together at the back of the classroom, with
no possible exit. He said to them: "Do you know why you are there."
One of the girls answered "No". He replied: "I am fighting
feminism." The student who had spoken added: "We are not feminists,
I have never fought against men." He immediately started firing on
the group, from left to right.

After having fired perhaps thirty shots, he left the premises, leaving
behind 9 victims, 6 of whom were among the victims who died.

Lépine then headed into the corridor opposite room C-229. He
fired on some people who were in the photocopier room, about 30 feet away
from him.

A boy and a girl were hit first and wounded. As he approached the two
people who had been shot, he wounded another student whose path he crossed.

Lépine then backtracked and headed toward room C-228. He went
into that room and stood at the entrance. He looked at the people there
and aimed at a female student at the back of the room, trying twice to
shoot her, but his weapon was not functioning.

He then left that room and went toward an emergency staircase near the
door of room C-229.

There, Lépine seemed to reload his weapon. At the same time,
a student coming down the emergency staircase from the second floor came
face to face with him. He heard Lépine say; "Oh shit, I'm
out of bullets." The student accidentally bumped into him and continued
along the corridor toward the photocopiers. Noticing three people lying
on the ground, he turned back around and looked at Lépine who was
reloading his weapon. When he saw him lift his weapon again, he left at
a run and got onto the escalators, heading for the cafeteria. He then
heard a shot.

Lépine then went back to the door of room C-228 and tried to
go into the room. He fired 3 shots into the locked door, trying unsuccessfully
to open it. He then went along the second-floor corridor, passing by 3
wounded people, and when he reached the foyer he crossed paths with a
female student who was coming from the escalator. Marc Lépine fired
on her and wounded her.

After that victim fell, she got back up and went down the corridor,
heading for the emergency staircase, and ultimately sought refuge on the
fifth floor.

Lépine then headed toward a semi-circle located in the foyer,
where one person was hiding behind a counter. After changing the magazine
of his weapon, while leaning on the counter, Lépine moved toward
the person who was hiding. When he had got within 8 feet of that person,
he aimed his weapon at the person and fired. Not having hit the person,
he fired a second time, but again without success.

Lépine walked around a bit in the second-floor foyer and on the
cafeteria terrace; he then went over near the financial services office
(room B-218), and ultimately moved opposite room B-211, about 20 feet
from the entrance to room B-218.

At that moment, a young woman locked the door to room B-218, and as
she was doing that, Lépine came back at a run to stop her from
closing the door, but without success. Through a window in the door, he
saw the young woman moving away, and he fired on her directly through
the window. She died from the shot.

It was now between 17:15 and 17:20.

Lépine headed toward the foyer. He then took the escalator, and
went to the cafeteria on the first floor, which he entered by door B-107.

It was now 17:20.

When he arrived at the cafeteria entrance, he aimed and fired at a female
student who was near the wall by the kitchens. She also died.

There were then about 100 people in the cafeteria, when the first shots
were fired, and they almost all left the room.

He moved slowly toward the other end of the cafeteria and fired several
shots in various directions, wounding another person.

When he reached the other end of the cafeteria, a room called the "polyparty"
- an unlocked storage area - he fired again on the 2 students who were
there. They are both among the victims who died.

Near that spot, Lépine told a male student and a female student
who were hiding under a table to get out from there, which they did without
being shot.

Lépine then left the cafeteria by door B-124 and went along the
corridor leading to the supplies room. He was then seen near the foyer
on the second floor, just before he got onto the escalator (not in operation)
to go to the third floor.

Lépine arrived on the third floor. Several people were in the
corridor, several shots were fired, and two male students and one female
student were wounded.

Lépine went down a small hallway, and after turning to the left
he came out about 15 feet farther away, in room B-311.

It was now about 17:25.

In that room, he took several steps toward the dais, and said to the
3 students who were giving a presentation: "Get out, get out."
He immediately fired on a student who was on the platform. He turned around
and fired again, on the students sitting in the first rows of the class.
Two female students who then tried to get away through the front door
of the room were wounded. Those students are also among the victims who
died. However, a number of students did succeed in getting away through
the back door of the room.

He then went down the aisle of the classroom, located near the corridor,
and fired on several people hiding between the rows of desks. Four people
were hit. These four people included one of the deceased victims.

Lépine then moved back and forth in the classroom several times.
He again replaced the magazine of his weapon, and got up on one of the
desks at the back of the classroom.

He then went back to the front, and again fired shots more or less in
every direction.

The student on the platform, the first one who was hit by Lépine
when he entered the classroom, asked for help. Lépine joined her
on the dais and, using a knife (a dagger), struck her three times. She
is also one of the deceased victims. He put down his knife (dagger) on
the instructor's desk, along with two boxes of 20 bullets each, and his
cap. He then said down on the dais. He took his coat off and put it around
the barrel of his weapon, and after speaking the words "Oh shit",
he killed himself by firing the last bullet in the magazine at his head.
Another full box of 20 bullets was found on a chair at the front of the
classroom near the entrance door.

It was now about 17:28 or 17:29.

Summing up, all of the individuals (including Lépine) were shot
when they were in the following precise locations:

- cafeteria (ground floor): four (4) individuals

- second floor corridor: four (4) individuals

- room B-218 on the second floor: one (1) individual

- room C-230.4 on the second floor: nine (9) individuals

- third floor corridor: three (3) individuals

- room B-311 on the third floor: eight (8) individuals

2.2.3 Other relevant facts

The following points should also be noted from the facts that are also
relevant to this case.

Marc Lépine had had a stable job for several years, until September
1988. In the fall of 1986, while he was employed in that job, he applied
to the Faculté Polytechnique at the Université de Montréal.
He was admitted on the condition that he complete two essential courses,
including the course in solution chemistry.

He subsequently drew unemployment insurance benefits for a period of
time ending on November 10, 1988. During that time, from March 1, 1988,
to September 22, 1988, he took courses at the Control Data Institute,
and then abandoned them. Ultimately, in the winter of 1989, Lépine
registered in and completed the solution chemistry course at the CEGEP
du Vieux Montréal.

In addition, Marc Lépine applied to the Sûreté du
Québec, on September 1989, for a firearms acquisition permit, which
he was granted.

He purchased the firearm used in the shootings on November 21, 1985,
at a store in Montréal.

In addition, Marc Lépine rented a car on the afternoon of December
5, 1989. The car was found the day after the incident, parked in the area
close by the Université de Montréal.

The final point of note is that a handwritten three-page letter was
found in the inside pocket of the jacket Lépine wore during the
shootings, and two letters addressed to friends were subsequently recovered.
They were all written by Marc Lépine and dated December 6, 1989.

2.2.4 Prior knowledge of the scene

Marc Lépine was very familiar with the area around the École
Polytechnique and possibly with the entire Université de Montréal
campus. It has been established that he was there on the following dates:

- September 11, 1985, when he made a purchase at the Polytechnique's
student cooperative;

- at least three (3) occasions between October 1, 1989, and October 31,
1989, when he was seen in the second-floor cafeteria, Room C-210;

- about November 22, 1989, when he was seen in the corridor of the Pavillon
Administratif building, which is located on campus, downhill from the
École Polytechnique;

- December 1, 1989, when he was seen in the École, the first time
in corridor B on the fourth floor and the second time on the second floor
near the bookstore;

- December 4, 1989, when he was seen in the École in the AEP office
located on the second floor, in room C-217;

- December 5, 1989, when he was seen first in the AEP office in room
C-217 of the École and then in the cafeteria in the Pavillon Administratif.

2.2.5 Absence of alcohol or drugs

It is important to note that based on the analyses done after the autopsy
performed on Marc Lépine's body, the following results were obtained:

- blood alcohol: negative;

- usual and abused drugs: not detected.

2.2.6 Weapons used

Based on the expert report prepared by the person in charge of the ballistics
section of the Laboratoire de police scientifique [forensic science laboratory],
the weapon used by Lépine in the shootings was a Sturm Ruger brand
rifle, mini-14 model, .223 calibre Rem., serial no. 185-34626, 5-, 20-
or 30- cartridge capacity, with a barrel length of 470 mm and overall
length of 943 mm.

After the incident, the following items were found at the scene, in
Room B-311, near the rifle: a 5-bullet capacity magazine, empty, and,
on the first chair in the third row, a 30-bullet capacity magazine, also
empty. As well, a second 30-bullet capacity magazine, also empty, was
found in the second floor corridor.

The rifle was in firing condition and had a trigger pressure of about
2.6 kg for single fire action.

The rifle is not connected with any pending case in the ballistics files
at the Laboratoire de police scientifique.

The weapon is designed and manufactured to fire projectiles at a speed
greater than 152.4 m/s (500 ft/sec).

The knife was a hunting knife (dagger) with a handle about four (4)
inches long and a blade six (6) inches long.

2.2.7 Profile of Marc Lépine

Marc Lépine was 25 years old and of medium size (5'10",
154 pounds). He was described by people who knew him, including his family,
as a not very social and not

very communicative person, except when he was talking about computers.
It was very difficult to get to know him. He was described as closed,
showing no emotion even about important things.

He did not accept authority, and this was said to have caused him problems
both at work and while he was a student. In addition, again according
to people who knew him well, Marc Lépine left nothing to chance.
Everything he did was planned down to the smallest detail.

A psychiatrist who was consulted during the police investigation formed
an opinion regarding the psychological and psychiatric profile of Marc
Lépine, which he based on information he gathered in interviews
with members of his family and his entourage, and from analyzing various
documents (letters) written by Lépine.

The following are excerpts from that psychological and psychiatric assessment:

- Marc Lépine defined suicide as the primary motivation for what
he did.

- He then described that suicide very specifically. He characterized
the multiple homicide situation as an extended suicide, or as an act of
multiple homicide/suicide.

- This specific suicidal strategy, killing one's self after killing another/others,
is a familiar one in forensic psychiatry.

- The multiple homicide/suicide strategy is also known to be a characteristic
of individuals who have a serious personality disorder.

- Such individuals may identify a person or group of persons negatively
and the collected aggressive emotions experienced may be projected onto
them.

In two documents, Marc Lépine identified feminists, women, as
the enemy, the bad thing to be destroyed. He regarded them as invested
with negative characteristics, based on a projective mode of thinking:
all the evil was on their side.

From the psychiatric point of view, the expert notes that his study cannot
be used to identify factors that suggest that Marc Lépine had a
functional psychiatric illness, nor is there any indication of any toxic
condition.

In addition, in the case of individuals who use the multiple homicide/suicide
strategy, this expert says, we find extreme narcissistic vulnerability,
manifested in the level of expectations and demands placed on themselves,
through fantasies of success and powerfulness, or through a desire and
need for recognition by others, through extreme sensitivity to rejection
and failure, through intolerance to depressing emotions that experience
as such only badly or to a slight extent. We also frequently find retreat
into a violent and sometimes grandiose imaginary life that is an attempt
to compensate for a fundamental feeling of powerlessness and incompetence.
In the psychiatrist's opinion, this description of the aggressive and
grandiose imaginary life found in such subjects is applicable to Marc
Lépine.

2.3 ACTIONS TAKEN

The event took place over a period of time, and the operations of the
various agencies involved began before the shootings ended, or in any
event before all the victims were known to be dead. It is therefore relevant,
and even crucial, to consider the role of the various agencies involved
in order to establish the complete circumstances of this case, as it is
the function of a Coroner's investigation to do.

In this instance, the actions taken by the École Polytechnique's
security service, the 9-1-1 emergency centre, Urgences-Santé, the
Montréal Urban Community police service (SPCUM) and the MUC's fire
service will be examined in this investigation report.

2.3.1 9-1-1 emergency centre

At 17:12:28:

- The first call was received by agent #36, position 616, and the caller
was a student at the École Polytechnique.

- The call lasted until 17:15:01. The student put the shootings on the
second floor; he explained that the individual had fired a shot and told
the boys to leave and kept the girls. Then, he said, he fired more or
less randomly. During this call, the agent was able to hear the shots
and a person moaning.

- During this conversation, the agent attempted to transfer the information
to the dispatch side of the police service. He experienced some difficulties
and was unable to transfer the call.

At 17:13:18:

- The second and third calls were received simultaneously.

- The second call was received by agent #97, position 606. The caller
was the security guard at the École Polytechnique.

At 17:15:51:

- The agent transferred the second call to Urgences-Santé. The
Urgences-Santé agent said that he had already been informed and
said that ambulances had already been dispatched to the scene. That call
lasted until 17:18:16.

- The third call, also at 17:13:18, was received by agent 85, position
613, and lasted until 17:25:15.

- Several other calls came in simultaneously. Details were provided regarding
the event. Again, a person moaning and gunshots could be heard.

Having regard to the seriousness of the situation, the person in charge
of the 9-1-1 centre tried to put one of the agents (#85) in direct contact
with SPCUM dispatch (S.I.T.I.). The sergeant in charge of S.I.T.I. refused,
asking instead that the information be taken and then transmitted. Subsequently,
the captain who was the assistant to the director and in charge of S.I.T.I.
allowed the caller to be transferred directly to dispatch.

2.3.2 Urgences-Santé

In this operation, Urgences-Santé assigned thirteen (13) ambulances,
five (5) doctor transports, one of which was accompanied by a trainee
nurse (#513) and three (3) coordination vehicles to the scene, in the
sequence described below. A sixth doctor transport, with no doctor, also
went to the scene, without being assigned.

In total, fourteen (14) persons were hospitalized, including one person
who went to hospital independently. Of the thirteen (13) people transported
by the ten (10) ambulances, four (4) were treated by Urgences-Santé
right outside the building.

2.3.2.1 Period preceding transmission of first call on air

At 17:15:

- Urgences-Santé received its first call from a person on the
scene of the event who said that someone had been shot at the École
Polytechnique on the Université de Montréal campus.

- A second call came in from another person also on the scene, who said
that an armed man at the Université de Montréal was firing
shots and that there were people wounded. The Urgences-Santé agent
told the person that an ambulance, a doctor and a police officer had been
sent and that they were on route.

- The third call again came from another person on the scene who said
that the event was taking place on the second floor of the École
Polytechnique on the Université de Montréal campus.

It should be noted that during these first three calls, the statement
that something was happening at the École Polytechnique on the
Université de Montréal campus seems to have been entirely
inadequate for the Urgences-Santé agents to immediately direct
emergency services. During the calls, demands were made for the precise
address, or, if not, the exact intersection.

At 17:15:42:

- The 9-1-1 centre transferred a call to Urgences-Santé concerning
the event, for the first time.

2.3.2.2 Period following transmission of first call on air and preceding
arrival of first vehicle on the scene

At 17:17:

- First resources assigned by Urgences-Santé. Three (3) vehicles
dispatched to the École Polytechnique on the Université
de Montréal campus, and were told via which intersection to go.
They were told that there were gunshot injuries and that there were two
(2) men and ten (10) women down. They were told that the police were en
route and asked to wait until the police arrived before going ahead.

- Doctor transport vehicle #502 was assigned.

It should be noted that simultaneously with this first assignment of
resources, a fourth call was received in which the exact street and location
of the event was again demanded. Gunshots could be heard in the background.

In the minutes that followed, Urgences-Santé again told its people,
several times, to proceed with caution because this was a crazy shooter.

It must be noted that initially, Urgences-Santé did not regard
the event as a disaster. The disaster procedure, which involves modification
to the assignment of resources and the use of the mobile command post
(vehicle 901) was only belatedly put into effect.

2.3.2.3 Period following arrival of first vehicle and preceding access
to interior

At 17:22:

- The first ambulance (#262) arrived on the scene. It took up a position
behind the security perimeter established by the police, several hundred
metres from the institution.

- That ambulance (vehicle # 262) asked that another ambulance (only one
more) be sent because it seemed to it that there were several injured
people and it could not get more details as long as it could not go and
look.

- The first doctor transport (#502) arrived on the scene.

- Ambulance # 289 was assigned.

At 17:24:

- The driver of ambulance # 262 informed dispatch that he had received
one (1) injured person and that apparently there were three (3) others.
He asked for two (2) more ambulances.

- Three injured persons made their own way to the emergency vehicles.
The doctor in vehicle #502 provided first aid.

At 17:27:

- Ambulances #211 and #268 were assigned.

- The driver of ambulance #262 requested an other doctor. He was told
that it wasn't certain that one could be sent, and the ambulance driver
requested that one in that part of the city at least be approached.

- The driver of ambulance #262 asked that he be given the name of a hospital
for transporting the first two victims who had come out on their own and
were not seriously injured. There was a little hesitation on the part
of the Urgences-Santé dispatch because it was afraid that a more
seriously injured person would come out before the other ambulances arrived.
Ultimately ambulance #262 was authorized to transport those two (2) inured
persons before the other ambulances arrived.

At 17:28:

- Doctor transport #508, with no doctor on board, arrived on the scene.
The driver of that vehicle had heard a call on air concerning the shootings,
and asked dispatch for permission to go there; despite the fact that dispatch
refused, he decided to go there anyway.

At 17:31:

- Doctor transport #502 told dispatch that there were more injured people
coming out of the building and that more ambulances had to be sent.

- Coordination vehicle #907 informed dispatch that it would be on the
scene in two to three minutes. Dispatch asked it to report how many ambulances
and doctor transports were needed.

At 17:36:

- Coordination vehicle #967, which had arrived on the scene, reported
that there were three ambulances (#221, #268 and #289) and one doctor
transport (#502) on the scene. It reported that no additional ambulances
were needed for the moment, but asked that one more doctor transport be
sent.

- Doctor transport #505 was assigned and arrived on the scene shortly
afterward.

At 17:37:

- Coordination vehicle #967 cancelled the request for the second doctor,
reporting that there was no need for the moment. Dispatch asked the second
doctor transport to take up a waiting position on the scene.

At about 17:41:

- Emergency medical services received authorization to enter the interior
of the institution, accompanied by police officers.

- The doctor in vehicle #502 and five (5) ambulance attendants crowded
into an ambulance and drove toward the entrance to the building located
several hundred metres farther away, escorted by four (4) police officers.

At about 17:43:

- Coordination vehicle #567 was with police vehicle 31-99 (director of
station 31).

At 17:44:

- Coordination vehicle #967 requested two more ambulances to be on stand-by.

- Coordination vehicle #967 repeated its request for two more ambulances,
stating that they should report to police vehicle 31-30. It said that
they were going to enter the institution.

- Dispatch informed coordination vehicle #967 that inside, on the second
floor, near the escalators, in the area of the photocopiers, in rooms
C-229 and C-230, there were two injured persons.

In total, five (5) persons were transported by the ambulances in this
first phase, which took place before the first emergency workers entered
the interior.

While they were waiting, the emergency medical services received no
information from the police. They were unable to assess the situation
until they had gone inside.

2.3.2.4 Period following access to interior

At 17:45:

- Dispatch tried to verify with coordination vehicle #967 whether the
two additional ambulances requested would be assigned to the two cases
on the second floor or whether ambulances #221 or #268 which were already
on the scene would be handling them.

- The first emergency medical workers, the doctor from vehicle #502 and
five (5) ambulance workers, entered the interior of the institution and
were taken by the police officers to the elevator from the ground floor.

- Those emergency medical workers did not go to the cafeteria because
the police said that there were injured persons only on the second and
third floors;

- The emergency medical workers got into the elevator alone, and, believing
that there were not other medical resources available, the doctor from
vehicle #502 divided the group into two. He delegated responsibility for
examining the victims on the second floor to the ambulance worker from
doctor transport #508. That ambulance worker got out of the elevator on
the second floor, accompanied by two (2) other co-workers, and took charge
of the victims on that floor.

- The rest of the group continued to the third floor. With no one to
guide them, they had trouble knowing where to go. They called out, and
a police officer in civilian clothing appeared and directed them to room
B-311. The doctor from vehicle #502 discovered, on entering, that five
(5) people were dead, and provided medical care to one other injured person.
According to a comment made to the doctor at that time by the police officer,
one of the victims, the victim lying in the middle of the classroom between
the rows of desks, was breathing until just before the doctor entered.

Before 17:46:

- Coordination vehicle #967 left its position to enter the interior of
the building.

Between 17:45 and 18:00:

- When the ambulance worker from doctor transport #508, who had been
given instructions by the doctor from vehicle #502 to do triage on the
second floor, got out on that floor with two (2) ambulance workers, he
first saw, at the end of the corridor, a patient in acceptable condition.
The group moved ahead, and halfway down the corridor, it discovered a
victim with a very serious head injury. One of the ambulance workers stayed
with her and the rest of the group continued. A little farther, they discovered
another victim, who, as verified by the ambulance worker from vehicle
#508, was apparently dead.

- When the approached room C-230.4, they saw three (3) persons lying on
the ground, but conscious. The ambulance worker from vehicle #508 then
asked his co-worker to go back and get his team and start the triage operation.

- During the assessment of those three (3) injured persons, the ambulance
worker from vehicle #508 asked another worker to go and get materials
and equipment.

- They then saw the six (6) victims at the back of the classroom. The
ambulance worker from vehicle #508 examined each victim and concluded
that they were dead.

- Doctor transport #505 and an ambulance were directed by a police vehicle
to the main entrance. The doctor from vehicle #505 and an ambulance worker
entered the interior and, with directions from students, went to the cafeteria
on the first floor.

- When the doctor from vehicle #505 entered the cafeteria, he determined
that a victim who had collapsed in a chair was dead.

- The doctor from vehicle #505 then learned from someone in civilian
clothing who was at the back of the cafeteria, probably a student, that
there were two other people who were apparently dead, but he did not go
and examine them.

At 17:47:16:

- Police vehicle 31-99 (director of station 31) requested another Urgences-Santé
coordinator at its command post to manage the ambulances.

At 17:48:

- Ambulances #204, #261 and #282 were assigned.

- Dispatch was told that with two doctors on the scene, no more were
needed.

At about 17:49:

- Coordination vehicle #967 informed dispatch that it was still waiting
for the resources it had requested.

In response to that communication from coordination vehicle #967, a
number of communications were undertaken for the benefit of ambulance
workers en route, specifying which routes to take.

At about 17:50:

- Ambulance #266 was assigned.

Between 17:50 and 17:55:

- The doctor from vehicle #502, at someone's request, went down from
the third floor to examine a young lady in a corridor on the second floor.
He determined that she was dead and went back up to the injured woman
on the third floor. After the stretcher arrived, he went into another
room on the third floor, where he provide medical care to two other injured
persons.

At about 18:00:

- The doctor from vehicle #502 met another doctor on the third floor,
who informed him that more injured persons had been seen on the fifth
floor and that they had been attended to. Medical care was then given
to a person with a minor injury who had taken refuge in another room on
the third floor.

- No more patients were found on the third floor, and so the doctor from
vehicle #502 then went downstairs with his team into the hall on the first
floor to await any developments.

It should be noted that at that time, the police wanted the medical
teams to stay in the various locations for as little time as possible,
primarily for their own safety and also to protect the crime scenes.

After 18:00:

- The doctor from vehicle #505 treated several injured persons who had
gone to the cafeteria.

- The doctor from vehicle #505 then went to a few floors. When he came
back down, he saw the doctor from vehicle #502 in a classroom on the third
floor near some victims and he did not need to assist. He probably stopped
on the second floor to check a few injured persons.

- It was about fifteen minutes after entering room C-230.4 on the second
floor, where there were three (3) injured persons and six (6) others who
were apparently dead, that the ambulance worker from vehicle #508 saw
that doctor appear and briefly question the injured victims and leave
again without examining the ones who were apparently dead. It was the
ambulance worker from vehicle #508 who provided medical care himself.

At 18:02:

- The first injured person was evacuated. This person had been seriously
injured.

Subsequently:

- Ambulances #317 and #276 were assigned.

At 18:07:

- Ambulances #302 and #324 were assigned, along with doctor transport
#513. As well, ambulance #289 was reassigned.

- Coordination vehicle #967 asked dispatch for more ambulances and was
informed that three (3) ambulances were then en route.

At about 18:10:

- After another person was sent to request resources, the first team
arrived to evaluate a patient from room C-230.4. The other two were evacuated
in the next ten minutes. Before leaving that room, the ambulance worker
from vehicle #508 examined the six (6) other victims a second time, to
be quite sure they were dead.

At 18:17:

- Ambulance #232 informed dispatch that it was going back to the scene.

At 18:18:

- The fourth ambulance, #515, reported to dispatch. Dispatch replied
that it should remain on stand-by because there had been no request.

At 18:24:

- The second coordination vehicle, #972, confirmed to dispatch that it
was on the scene.

At about 18:25:

- Doctor transport #513 arrived on the scene. The doctor entered the
interior and checked on the various floors (with the exception of the
second floor) to see whether his services were required. He then went
to the main hall to remain available, following the instructions of the
police officers.

At 18:34:

- The assistant head of ambulance services, vehicle #901 (CNCC), contact
dispatch from the scene.

That vehicle is a mobile command post, with portable radios on board,
and is meant to be used in the case of a disaster. It must be noted that
its efficacy was of little significance in this situation because of the
late point at which it arrived and the poor operating condition of its
radio equipment.

At 18:36:

- The person in charge of emergency medical services (CNCC) (vehicle
#901) on site at that time confirmed to dispatch that all ambulances were
en route to hospitals.

From 18:02 to 18:41:

- There were several communications between the ambulance workers and
dispatch concerning the evacuation of the injured persons (the first evacuation,
of a victim who had been attended to inside the institution, took place
at 18:02, and the last at 18:41), the nature of their injuries and the
hospitals to which they were to be taken.

At about 18:41:

- Last injured person transported.

- The person in charge of Urgences-Santé (CNCC) on site at that
time informed dispatch that doctor transport #505 would be back on the
road in a few minutes.

At about 19:00:

- The doctor from vehicle #505, after first going past the victim lying
in the corridor on the second floor, checked that victim to be sure there
was no pulse, using a monitor, to eliminate any doubt.

At about 19:15:

- The doctor from vehicle #513, who was waiting in the main hall, was
informed by the police that two more victims had been discovered in the
cafeteria. He went there and determined that they were dead.

During this second phase, the phase after the first emergency workers
entered the inside of the building, eight (8) persons were evacuated and
transported to a hospital.

Throughout the event, the following ambulances transported injured persons:

- The injured victim in the cafeteria: she went to hospital herself.

- The three (3) injured victims in room C-230.4: by vehicles #261, #307
and #282.

- The four (4) injured victims in the second floor corridor: by vehicles
#266, #268 and #289; and one victim who came out of the building on her
own: by vehicle #262.

- The three (3) injured victims in room B-311: by vehicle #204; and the
victims who came out of the building on their own: by vehicles #317 and
#289.

- The three (3) injured victims in the third floor corridor: by vehicles
#268 and #221; and one victim who came out of the building by herself,
by vehicle #262.

With respect to the deceased victims who were not transported to a hospital,
the deaths were determined by the following persons:

- The three (3) victims in the cafeteria: one (1) victim by the doctor
from vehicle #505 at about 17:45, and two (2) victims by the doctor from
vehicle #513 at about 19:15.

- The six (6) victims in room C-230.4: by the ambulance worker from vehicle
#508 at about 1:45 (no determination of death by a doctor).

- The victim in room B-218: by the doctor from vehicle #502 between 1:50
and 17:55 and the doctor from vehicle #505 at about 19:00.

- The five (5) victims in room B-311: by the doctor from vehicle #502
between 17:45 and 17:50.

Doctor transport #502 stayed on site to assist witnesses and families
of the victims. Doctor transport #510 arrived on the scene at 00:50 to
relieve doctor transport #502.

Doctor transport #502, which reported at 18:18, remained outside. Its
presence was not required inside.

Once inside, because of the lack of adequate equipment, emergency medical
workers were unable to communicate among themselves or with the resources
outside the building, and this made it more difficult for them to perform
their functions.

In addition, in the course of the process of assessment and triage of
the injured persons, emergency workers did not have the materials they
needed for identifying patients, and this may have resulted in omissions
or duplications. The entire triage process suffered from the absence of
a clearly defined protocol.

We would also note that the presence of several armed police officers
and police officers in civilian clothing was briefly a cause of some concerns
among the emergency medical workers.

In addition, after an initial phase involving the evacuation of injured
persons, the unfounded and uncontrolled rumour that there might be a second
suspect resulted in medical resources being temporarily recalled.

In general, it appears that the absence of precise directives concerning
the disaster plan was a subject of severe criticism by some of the medical
workers.

2.3.3 SPCUM

2.3.3.1 Period preceding transmission first call on air

At 17:15:58:

- The call was transmitted to the 9-1-1 centre.

Having regard to the seriousness of the situation, the person in charge
of the 9-1-1 emergency centre tried to put one of his agents in direct
contact with dispatch (S.I.T.I.) and the supervising sergeant at S.I.T.I.
refused, and asked instead that the information be taken and transmitted.
Subsequent intervention by the captain in charge of S.I.T.I. and assistant
to the director resulted in it being possible to transfer a caller directly
to dispatch.

2.3.3.2 Period following transmission first call on air and preceding
arrival of first vehicle on the scene

At 17:17:58:

- The call was dispatched for the first time to the vehicles at station
31.

At that time, the call was transmitted for 2500 Édouard-Montpetit
with the code 214 SU, that is, "abduction, hostage-taking and confinement".
The suspect was holding twenty (2) girls hostage, at rifle-point, in room
C-229, and had fired shots in the air. It was given to vehicle 31-4 (2
police officers), vehicle 31-85 (the sergeant) and all vehicles at station
31.

The dispatch agent, using a computer, on channel U-1, repeated the call
and said that she had no further information and although she had been
informed that the event was taking place at the École Polytechnique,
she did not provide details.

- 31-85 (the sergeant) was informed over the air that 31-95 (the lieutenant)
had been informed that there were injured persons. 31-85 then requested
that Urgences-Santé attend.

At 17:19:06:

- vehicle 31-7 (2 police officers) stated that it would be on the scene
in thirty (30) seconds, at the Tour des Vierges (women students' residence).
It asked what building it should go to.

The first vehicles, 31-7 (2 police officers) and 31-4 (2 police officers),
went to the student residence, believing that 2500 Édouard-Montpetit
was the address of that building.

At about 17:19:

- the operations director for the northern region was on the scene, by
chance, having gone there to pick up his son, a student at the École
Polytechnique. His son informed him that there may have been gunshots
inside the building.

At 17:19:47:

- Information was given on air stating that the scene was on the second
floor of the École Polytechnique, that the man was armed, that
he was shooting and that there were injured people inside the building.

At about 17:20:

- 31-99 (the director of station 31), which was then on the road, reported
that it was going to the scene and asked 31-95 (the lieutenant) to go
there.

At 17:20:34:

- The operations director for the northern region requested emergency
cars for the École Polytechnique on channel U-4.

At 17:22:06:

- 31-99 (the director of station 31) asked for the Groupe Technique [technical
squad], which was responsible for crime scenes.

2.3.3.3 Period following arrival of first vehicle on the scene and preceding
access to interior

At 17:22:08:

- Vehicles 31-7 (2 police officers) and 31-4 (2 police officers) informed
S.I.T.I. that they had arrived on the scene. They stated that there were
several injured persons and requested ambulances. They were told that
ambulances were en route.

- At the point when the operations director for the northern region informed
the dispatcher that he wanted to enter the École by the main entrance
(students' entrance), he heard police vehicles approaching and decided
to wait for them and enter as a group.

- He was still on air on channel U-4 and asked the vehicles to join him
at the main entrance. They were unable to hear him because they were all
on channel U-1. He therefore went toward them, lower down, opposite the
main students' entrance, the location that then became the command post
for the police operations.

Vehicle 31-4 (2 police officers) assumed the leadership of the operation
before its supervisor arrived and positioned some vehicles to establish
a security perimeter several hundred metres from the institution, outside
the parking area.

31-4 then exchanged information with the operations director of the
northern region. At that point, it was incorrectly believed that there
were only three vehicles on the scene and they were waiting for more resources
before taking action.

- While en route, 31-99 (the director of station 31) requested that the
exits be covered.

The first ambulances to arrive at the command post attended to the injured
persons who had come out of the building on their own. Vehicle 31-4 was
at the command post with the ambulance workers. Vehicles 31-2 and 31-7
dispersed the crowd and directed the injured persons to the command post.

At 17:24:54:

- The call from a student was transmitted directly by dispatch over channel
U-1. He reported several gunshots and injuries.

At 17:26:16:

- Another student gave a description of the suspect, his weapon, his
weight and his age, directly over channel U-1.

At 17:28:51:

- The dispatcher retransmitted the description over the air.

At 17:26:56:

- Vehicle 31-2 transmitted information to the effect that the suspect
was on the fourth floor and the suggestion made by a student that the
fire alarm be set off. The dispatcher gave permission to set the alarm
off.

- That permission was countermanded by a decision by 31-99 (the director
of station 31) but the alarm was already ringing.

At 17:27:16:

- Vehicle 31-85 (the sergeant) arrived on the scene and coordinated its
actions with the operations director for the northern region, who was
formulating several intervention strategies. Additional resources were
requested and they asked whether vehicle 31-99 (the direction of station
31) was en route.

- It was still incorrectly believed that there were only five (5) vehicles
on the scene: vehicles 31-4 (2 police officers), 31-7 (2 police officers),
31-2 (2 police officers), 40-99 (the operations director for the northern
region) and 31-85 (the sergeant).

In fact, there were several vehicles, but they had not all confirmed
their arrival to the dispatcher or had not all informed the command post
of their presence.

As of 17:22, the following vehicles were in fact on the scene, in addition
to vehicles 40-99 (operations director for the northern region), 31-4
(2 police officers), 31-7 (2 police officers) and 31-2 (police officer):

- vehicle 31-135 (2 police officers) which arrived at about 17:21 and
took up a position near the students' entrance;

- vehicle 31-143 (1 police officer) which arrived at about 17:22 and
joined 31-7 at the students' entrance;

- vehicle 31-71 (1 police officer) which arrived at about 17:22 and took
up a position at the intersection of Côtes-des-neiges and Decelles
to control traffic;

- vehicle 31-70 (1 police officer) which arrived at about 17:22 and took
up a position at the intersection of Édouard-Montpetit and Louis-Collin
to control traffic. That vehicle informed dispatch of its arrival on the
scene but the command post was not informed;

- vehicle 31-15 (1 police officer) which arrived at about 17:22 and went
to the command post, and at its request went to station 31 to get four
bullet-proof vests;

- vehicle 31-133 (2 police officers) which arrived at about 17:22 and
took up a position opposite the main door on the north side;

- vehicle 31-66 (1 police officer) which arrived at about 17:22 and took
up a position at the intersection of Chemin de la Rampe and Chemin de
la Polytechnique to control traffic.

Summarizing, by 17:22 there were eleven (11) police vehicles with a
total of sixteen (16) police officers, including a superior officer, on
the scene.

In addition, within the next two (2) minutes, three (3) more vehicles
arrived, bringing six (6) more police officers, so that when vehicle 31-85
(the sergeant) arrived at 17:27:16, there were a total of fourteen 914)
vehicles with twenty-two (22) police officers already on the scene. The
last three (3) vehicles to arrive were:

- vehicle 31-1 (2 police officers) which arrived at about 17:23 and took
up a position near the main door on the north side;

- vehicle 31-141 (2 police officers) which arrived at about 17:24 and
took up a position facing the students' door at the southwest corner;

- vehicle 31-132 (2 police officers) which arrived at about 17:24 and
took up a position at the southwest corner of the École.

The police action at that time consisted of securing the perimeter,
evacuating the crowd, particularly from around the entrances, and assisting
the injured persons who came out of the building.

From 17:27:16 to 17:26:16:

- The dispatcher received information from a student that she retransmitted
over the air, to the effect that the suspect was on the fourth floor,
that he had an repeat-firing weapon, that he was shooting at everybody,
and that there were several very seriously injured people.

At 17:29:28:

- 31-85 (the sergeant) said that his command post had been set up uphill
on the campus across from the d-p and that downhill there was a police
vehicle that was directing the ambulances. He requested more vehicles
to do crowd control.

At 17:31:16:

- 31-95 (the lieutenant) reported that he was on his way.

- 31-2 (2 police officers) reported that they could get in through the
garage and 31-85 (the sergeant) replied: negative; no one goes in for
the moment.

At 17:31:36:

- Vehicle 31-134 (2 police officers) informed 31-85 (the sergeant) that
there were several police officers in civilian clothing available for
the command post.

- The dispatch centre asked 31-85 (the sergeant) to report the location
of his command post.

At 17:32:45:

- 31-7 transmitted the information received that there were a number of
people in room B-301 and the cafeteria who were dead.

At 17:33:01:

- The dispatch centre again asked 31-85 (the sergeant) to report the
location of his command post to let 31-95 (the lieutenant) know.

At 17:34:13:

- 31-85 (the sergeant) requested more vehicles. The dispatch centre replied
that the technical squad was en route. 31-85 (the sergeant) reiterated
its request for four additional vehicles.

At 17:34:16:

- 31-17 confirmed that it was on the scene.

At 17:34:16:

- 31-99 (the director of station 31) arrived on the scene. He exchanged
information with 31-85 (the sergeant) and the operations director for
the northern region.

At 17:35:52:

- 31-99 (the director of station 31) gave information to 31-95 (the lieutenant);

- 31-7 reported the information received, that the suspect had killed
himself on the third floor.

2.3.3.4 Period following access to interior by the first police officers

- 31-99 (the director of station 31) took command of the operation. He
requested the mobile unit and he was informed that thirteen officers and
a superior officer from the tactical squad were en route.

At 17:38:16:

- 31-99 (the director of station 31) asked 31-150 (2 police officers)
and 31-4 (2 police officers) to go in with the ambulance workers to attend
to the injured persons. They went into the building at about 17:45.

At 17:38:32:

- The dispatch centre informed 31-99 (the director of station 31) that
the suspect was reported to be in room B-218. 31-99 asked dispatch to
send him two investigators.

At 17:39:59:

- 31-2 (2 police officers) urgently asked to have ambulance workers go
in to the second floor, stating that there were some ten injured persons
and confirming that that floor had been secured, and went to room B-311.

- When they arrived with the first group of police officers, at 17:36:16,
those two police officers went directly to the second floor. One of the
two requested medical assistance and the other, on information received
from a professor, went directly to room B-311. He was the first police
officer to enter that room and that was where he located the suspect,
who had committed suicide.

- 31-143 (1 police officer), also in the first group to enter the building,
also went, with other police officers, to room B-311. He requested ambulance
workers for a number of injured persons in that room. He confirmed that
the suspect had committed suicide.

At about 17:40:

- In response to information that there was an injured woman in the cafeteria,
vehicles 31-133 (2 police officers) and 31-135 (1 of the 2 police officers)
entered by the main door on the north side and went to the cafeteria to
look for that victim.

- 31=7 (2 police officers) also requested ambulance workers urgently
for a victim with a bullet in her skull in room B-311 and reported that
there were six (6) seriously injured persons on the second floor.

At about 17:43:

- 31-85 (the sergeant) entered the interior and went to room 230-4. Because
communication via walkie-talkies was non-functional, he went back to get
ambulance workers.

At 17:43:31:

- 31-95 (the lieutenant) requested several ambulances at the entrance.

- An Urgences-Santé coordinator (vehicle #967) was with 31-99
(the director of station 31).

- The technical squad, composed of ten (10) police officers, including
two (2) sergeants, arrived on the scene.

At 17:45:39:

- More requests for ambulance workers were made by 31-7 (2 police officers),
to evacuate four (4) injured persons, two (2) of whom were seriously injured.
One of those two (2) police officers had gone to the second floor (corridor
and room C 230 4) and the other had gone immediately to rooms B-311 and
B303.

Before 17:45:39:

- The Urgences-Santé coordinator (vehicle #967) left the command
post to enter the interior. It then became necessary to go through the
dispatch centre to request more ambulances.

At 17:47:16:

- 31-99 (the director of station 31) requested another coordinator for
the command post, to manage the ambulances. The coordinator from vehicle
#972, and then the assistant head of ambulance services (vehicle #901),
subsequently got involved.

- 31-134 (1 of the 2 police officers) also requested ambulance workers
for the person in room B-311 who had been injured by a bullet to the head.

At 17:49:26:

- 31-95 (the lieutenant) asked all police officers to remain outside
and to monitor the perimeter.

- 31-99 (the director of station 31) asked the police officers inside
the building for information on the suspect's position.

- 31-4 (2 police officers), who had gone in at 17:41 and who were moving
from one scene to another, replied that the suspect was in B-311 and confirmed
that it was safe to enter the interior of the building.

- 31-95 (the lieutenant) repeated his request that the other police officers
remain outside the building and prevent people from entering.

At 17:54:16:

- 31-99 (the director of station 31) asked the police officers to prohibit
access and to protect the crime scenes.

- 31-95 (the lieutenant) entered the interior with the members of the
technical squad.

- He was followed by 31-99 (the director of station 31).

A number of requests for ambulance workers were again made from inside
the building for victims located in rooms B-311, A-583, A-281, B-303 and
B-210.

Vehicle 31-99 (the director of station 31) installed his command post
at the security guards' station and toured the premises. He was accompanied
by the operations director for the northern region.

Vehicle 31-85 (the sergeant) coordinated personnel from the interior
with the sergeant in charge of the tactical squad.

Summarizing, the following police officers went to the various locations
and rooms to locate all the victims, in the first few minutes after they
entered the building, with the exception of the two persons at the far
end of the cafeteria (polyparty room) who were dead and who were not discovered
until 19:15:

- the cafeteria: vehicles 31-133 (2 police officers), 31-135 (1 of the
2 police officers) and 31-131 (1 of the 2 police officers). It was the
police officers from vehicle 31-133 who were in charge of securing the
scene in the cafeteria who discovered the last two victims at 19:15;

- the second floor corridor: vehicles 31-2 (1 of the 2 police officers),
31-7 (1 of the 2 police officers), 31-131 (1 of the 2 police officers)
and 31-134 (1 of the 2 police officers);

- moving from one scene to another on the various floors: 31-4 (2 police
officers), 31-85 (the sergeant), 31-95 (the lieutenant) and 31-99 (the
director of station 31).

At about 18:20:

- A detective lieutenant arrived on the scene. He informed himself about
the situation, met with 31-99 (the director of station 31) and requisitioned
the resources needed for the investigation portion.

- While there was an operation underway in the St-Léonard area
involving the entire Crimes contre la personne [crimes against the person]
division, the officers in charge had been informed that there was a shooting
at the École Polytechnique, at about 18:00. A majority of the investigators
were dispatched to the scene and the first ones arrived at about 18:20.

At about 18:45:

- The director of the crimes against the person division arrived on the
scene, and took charge of the operations at about 19:00.

At about 19:15:

- Two victims were discovered in the cafeteria.

At about 20:00:

- At the request of the police officers, the person in charge of security
unlocked all the rooms that had not yet been inspected, to allow for a
systematic search in order to ensure that there were no other victims.

2.3.4 Université de Montréal or École Polytechnique
security service

At 17:15:

- A professor went to the security service's guards' station and told
the guard that an armed individual was accosting the students in C-230-4.

From 17:15 to 17:40:

- While gunshots could be heard, a number of calls were made by the guard
to the 9-1-1 centre.

At 19:10:

- The person in charge of the security service arrived on the scene with
his assistant.

At about 20:00:

- All of the available guards were called so that they could provide
assistance.

- At the request of the police, the security service unlocked the doors
of all the rooms to allow for a search by the police in order to ensure
that there were no more victims.

At the request of the SPCUM, the Polytechnique's security service took
charge of the personal effects abandoned by the students in the classrooms.

2.3.5 Fire service

At about 17:27:

- The fire alarm was set off at the suggestion of a student and with
the authorization of the SPCUM dispatcher.

Eight (8) vehicles were dispatched to the scene. No operations were
undertaken by this service.

2.4 TIME

It is impossible to overemphasize the importance of pre-hospital care
in the initial treatment of victims of traumatic injury. The primary objective
is to reduce the time taken to reach the patient to a minimum, in order
to determine the care, through appropriate triage adapted to the patient's
needs, the situation and the available resources. Specially equipped ambulances,
medical personnel qualified in emergency situations and the capacity to
reach the patients as quickly as possible represent the basic requirements
for ensuring that this objective as achieved.

Accordingly, the effectiveness of emergency services in emergency situations
is measured, first and foremost, by response time. This is true in all
cases and for all emergency personnel and services. This is why it is
important to examine all of the actions taken from the standpoint of the
response time for each one.

The times may be summarized as follows:

2.4.1 9-1-1 Centre

(a) from the time when the first call to the 9-1-1 centre began (17:12:28)
to the time when the relaying of the request to Urgences-Santé
began (17:15:51), 3 minutes and 28 seconds elapsed; (b) from the time
when the first call to the 9-1-1 centre began (17:12:28) to the time when
the relaying of the request to S.I.T.I. (SPCUM) began (17:15:58), 3 minutes
and 30 seconds elapsed.

2.4.2 Urgences-Santé

(a) from the time when the first call to Urgences-Santé began
(17:15:00) to the first transmission over the air (17:17), 2 minutes elapsed;

(b) from the time of the first transmission over the air (17:17) to the
arrival of the first ambulances on the scene (17:24:16), about 7 minutes
elapsed;

(c) from the time of the arrival of the first ambulances (17:24) to the
arrival of the mobile command post (vehicle #901) (18:11), 47 minutes
elapsed;

(d) from the time of the arrival of the first ambulances (17:24) to the
entry of the first emergency medical workers into the interior (17:45),
21 minutes elapsed;

(e) at the time of the entry of the first emergency medical workers (17:45)
about 9 minutes had elapsed from the receipt by the police of information
regarding the suicide of the suspect (17:35:52);

(f) from the time of the entry of the first emergency medical workers
(17:45) to when the last injured person was transported (18:41), 56 minutes
elapsed.

2.4.1 SPCUM

(a) from the time when the request was relayed to S.I.T.I. (SPCUM) (17:15:58)
to the time when the first transmission of the request over the air began
(17:17:58), 2 minutes elapsed;

(b) from the time when the request was relayed to S.I.T.I. (SPCUM) (17:15:58)
to the time when the request for tactical squad involvement was made (17:24),
about 8 minutes elapsed;

(c) from the time when the transmission of the request over the air began
(17:17:58) to the time when confirmation of receipt of the request by
a police vehicle began (17:18:06), 8 seconds elapsed;

(d) from the time when a police vehicle (31-4) confirmed receipt of the
request (17:18:06) to the time when the first police vehicle (31-135)
arrived on the scene (17:21), 2 minutes and 54 seconds elapsed;

(e) from the time when the first police vehicle arrived on the scene
(17:21) to when the information that the suspect had committed suicide
was transmitted for the first time (17:35:52), 14 minutes and 52 seconds
elapsed;

(f) from the time when the information that the suspect had committed
suicide was transmitted for the first time (17:35:52) to when the first
police officers entered the interior (17:36:16), 24 seconds elapsed;

(g) from the time when the information that the suspect had committed
suicide was transmitted for the first time (17:35:52) to when the police
authorized the ambulance workers to enter the interior (17;41), about
5 minutes elapsed, and it was 9 minutes until the first emergency medical
workers actually entered the building.

From the time when the first call to the 9-1-1 centre began (17:12:28)
to the time when the first police vehicle arrived on the scene (17:21),
a total of 8 minutes and 32 seconds elapsed, and from the time when the
first police vehicle arrived (17:21) to the time when the first police
officers entered the interior (17:36:16), 15 minutes and 12 seconds elapsed,
for a grand total of 23 minutes and 44 seconds.

With the exception of the two victims who were dead and who were discovered
in the cafeteria (in the polyparty room), the victims were located within
the first few minutes after the police entered the interior.

2.5 COMMENTS

In addition to establishing the probable causes and circumstances of
a death, and whether the Coroner is acting in the course of an investigation
or in the course of a public inquest, the Coroner may make recommendations
for the purpose of ensuring that human life is better protected.

It goes without saying that to that end, it is important to examine
this case as a whole and to report any failings or deficiencies identified.

This examination prompts a number of comments and raises several questions.

For the purposes of making those comments and stating the relevant questions
fairly, we need to review some of the facts and observations set out above.

2.5.1 9-1-1 Centre

As has been pointed out, the primary objective in all emergency situations
is to reduce the time needed for reaching the person or persons who need
assistance to a minimum. This is referred to as the response time.

The response time period does not start merely at the point when the
request for assistance is received; rather, it starts at the very moment
when the need for assistance arises, that is, at the very moment when
the incident that results in that need for assistance occurs.

Accordingly, for the purpose of reducing emergency services' response
time as far as possible, it is essential, first, to have access as soon
as possible to a means of communication, to be able to identify, without
delay, the location to be communicated with to request the necessary assistance,
for immediate and effective assistance to be given there, and for the
request for assistance to be transmitted efficiently without delay to
the appropriate emergency services.

This, therefore, is the chain of the various initial stages that are
desirable in order to achieve the result of minimum response time.

The 9-1-1 centre's objective is, among other things, to respond to this
need. The effect of the existence of an emergency centre that can be contacted
by a single, simple telephone number (9-1-1) that is known to the public,
and that centralizes all emergency requests and transfers them to the
appropriate emergency services, must be to keep the initial stages of
response time to a minimum.

2.5.1.1 Observations

Access to a telephone was not a source of problems in this case. A number
of people in fact contacted Urgences-Santé directly, rather than
calling the 9-1-1 centre.

During the first call, some problems arose when the centre tried to
transfer the information to the SPCUM.

The need to have the caller provide the exact address of the place where
the event was taking place, despite the fact that it was a major public
place and was clearly identified, resulted in delays.

The disagreement that arose at the beginning of the operations, between
the 9-1-1 centre and S.I.T.I. (SPCUM), regarding whether the caller could
be transferred directly, slowed down the transmission of certain important
information to the appropriate emergency services.

The times of 3 minutes and 23 seconds and 3 minutes and 30 seconds,
respectively, which elapsed between the time when the first call received
by the centre began and when the first transmission of the request for
assistance to Urgences-Santé and S.I.T.I. (SPCUM) began are simply
too long.

2.5.1.2 Questions

- Is the public in the Montreal Urban Community sufficiently well-informed
about the importance of calling 9-1-1 in the event of an emergency:

- Do the technical difficulties encountered in transferring the first
call to S.I.T.I. (SPCUM) call for a review of equipment and facilities,
or the processes for using them?

- Is there a strict procedure that, in some cases, allows for a caller
to be transferred directly to S.I.T.I. (SPCUM)?

- If so, are agents at the 9-1-1 centre and S.I.T.I. (SPCUM) properly
informed about it?

- Should the 9-1-1 centre not be able, armed with only the name of a
public building, to ensure that the building can be located immediately,
at least in the case of buildings that have large numbers of users?

- Are there clearly defined protocols for ensuring that, in a minimum
of time, the essential information is taken and immediately transferred
to the appropriate emergency services:

- If so, are the agents at the 9-1-1 centre adequately trained to follow
those protocols?

2.5.2 Urgences-Santé

The importance of pre-hospital care in the initial treatment of victims
of traumatic injury was stressed earlier. In addition to reducing the
time for reaching patients to the extent possible, the time taken for
determining care, through appropriate triage adapted to needs, the situation
and the resources available, must also be reduced. As noted earlier, specially
equipped ambulances, medical personnel who are qualified in emergency
situations and the capacity for enough personnel to reach patients as
quickly as possible represent the basic requirements for ensuring that
this objective as achieved.

2.4.2.1 Observations:

The first three calls received by Urgences-Santé came directly
from people at the Polytechnique.

During those calls, the statement that the event was taking place at
the École Polytechnique located on the campus of the Université
de Montréal also seemed to be insufficient for the Urgences-Santé
agents to be able to immediately direct emergency services properly.

The first calls received by Urgences-Santé were not transmitted
to either the SPCUM or the 9-1-1 centre. It was when the first communication
was received from the 9-1-1 centre that Urgences-Santé informed
that centre that it was already aware of the event.

The two (2) minutes that elapsed between the time when the first call
received by Urgences-Santé began and the time when the request
for action was first transmitted over the air was too long. However, that
time is of no consequence in this instance.

Some ambulance drivers had trouble finding the right route.

During the seventeen (17) minutes' waiting time that preceded authorization
to enter the building, medical emergency services received little or no
information from the police.

Urgences-Santé did not consider the event to be a disaster at
the time when it should have. The late arrival of the vehicle that was
the mobile command post made it of little or no use.

The inadequacy of the emergency medical services available at the time
authorization to enter the building was given, and the absence of functioning
communications equipment inside the building, increased the length of
time that elapsed until the last injured person was transported.

The emergency services teams did not have the materials needed for identifying
patients during the triage process.

The triage and patient assessment process was carried out without following
a clearly established and defined protocol.

The disaster plan was poorly defined and the medical services workers
were not familiar with it. The operation as a whole suffered as a result.

2.5.2.2 Questions

- Because it seemed, from the first calls received by Urgences-Santé,
that this was an event calling for immediate action by the police, and
given that the calls came directly from users rather than from the 9-1-1
centre, why did Urgences-Santé not make arrangements without delay
to inform S.I.T.I. (SPCUM)?

- Should Urgences-Santé not be able to locate a public building
immediately, from its name alone, at least for buildings with large numbers
of users?

- Is there a strict directive for an ambulance worker assigned to the
scene of an event to report to his or her dispatch without delay if the
worker is unable, or foresees being unable, to determine the appropriate
route for getting there?

- Are there clearly defined protocols for taking the essential information,
assigning the appropriate emergency services and transmitting the relevant
information, in a minimum of time?

- If so, did the Urgences-Santé agents have adequate training
for following those protocols?

- Should there not be a strict procedures established so that when a
criminal and medical event occurs, there is a systematic exchange of information
between the police and emergency medical services, so that the medical
emergency services are able to plan their actions appropriately?

- Should the disaster plan not be better defined?

- Who has responsibility for setting the disaster plan process in motion,
and at what point and based on what criteria?

- On what basis and in what circumstances should agents report to their
supervisor any information that might set the implementation of the disaster
plan in motion? Are they trained for this purpose?

- At what point should the vehicle that is to be the mobile command post
be assigned?

- What equipment should be specially used when the disaster plan is implemented?

- What are the communications devices?

- Are they functional inside buildings?

- What materials are needed for identifying patients and categorizing
them based on the seriousness of their injuries?

- Who has responsibility for maintaining that equipment and those triage
materials and for ensuring that they are available without delay when
needed?

- How is direction of operations in the event of a disaster assumed,
and by whom?

- How are emergency medical services coordinated with police operations,
and by whom?

- Are Urgences-Santé personnel trained for the specific operations
that result from the setting in motion of the disaster plan?

- Are there clearly defined protocols concerning the assessment and
triage of patients?

- If so, are Urgences-Santé personnel adequately trained in those
protocols?

- Why were the deaths of the victims in room C-230.4 on the second floor
not determined by a doctor, when there was an additional doctor waiting
on the outside and no one had requested his services?

- Was this a lack of coordination?

2.5.1 SPCUM

It should be noted, again, that the quality of the services provided
in an emergency situation is measured, first and foremost, by the services'
response time, and then by their efficiency in performing their functions.

2.5.3.1 Observations

The first request for emergency services was transmitted over the air
after some time had already elapsed: two minutes after receipt of the
request by the 9-1-1 centre began. That request was made to all vehicles
from police station 31, and related to 2500 Édouard-Montpetit although
it was not specified that this was the École Polytechnique, even
though the dispatch agent had been informed of this.

The code used in that transmission referred to an abduction, hostage-taking
and confinement case. It was said that a group of twenty (20) girls had
been taken hostage and that the suspect had fired shots in the air. Dispatch,
however, had already been informed that there were injured persons. Nonetheless,
the information about the presence of injured persons was transmitted
to the vehicles before they arrived on the scene.

A disagreement arose briefly in the first few moments, between the 9-1-1
centre and S.I.T.I. (SPCUM), regarding whether to permit a caller to be
transferred directly.

The nearly three (3) minutes that the first vehicles took to arrive
on the scene was caused in part by the fact that it was not stated at
the outset that the location was the École Polytechnique. Although
the serious of the situation was apparent from the first information received,
the tactical squad was not called in until eight (8) minutes after the
dispatch centre was informed of the nature of the event, and even about
two (2) minutes later than the information transmitted to the technical
squad.

From the time when the first police vehicle arrived on the scene to
the time when the police learned that the suspect had killed himself,
about fifteen (15) minutes elapsed. In other words, the police learned
the suicide information about twenty (20) minutes after the first call
they received concerning this event, and twenty-three and a half (23½)
minutes after the first [call] made to the 9-1-1 centre began.

Throughout all that time, the police actions consisted of securing a
security perimeter and evacuating the crowd. At the point when it was
announced that the suspect had killed himself, there was a very large
number of police officers on the scene, who had been there for approximately
fourteen (14) minutes - about six (6) or seven (7) minutes before Marc
Lépine actually killed himself.

However, the police did not know the exact number of resources available.
Some of them had not confirmed their arrival to the dispatch centre or
to the command post established on the scene. When it was announced that
the suspect had killed himself, therefore, the police were waiting for
reinforcements. At that point, no intervention operation was underway
and none was in the process of being executed, or even being formulated.

During the period preceding the announcement of the suicide, a number
of police officers, in turn, took charge of the operation, and even, for
a moment, some of them even at the same time.

Little or no information was provided to the emergency medical services
on site regarding the situation inside the building.

No effective connection was established with the École's security
service, in order to obtain details about the status of the situation,
a description of the scene and an estimate of the number of users inside,
although the guard communicated with dispatch, through the 9-1-1 centre,
several times. There was some confusion among the police regarding whether
the fire alarm should be used to force the evacuation of the building.

Bullet-proof vests were not available in the vehicles. On the initiative
of the first senior police officer on site, a vehicle already on the scene
was sent to the station to get them.

About five (5) minutes elapsed between when the suicide was announced
and when the ambulance workers were given authorization to enter the interior.
That operation was not prepared in advance, and so it took about four
(4) minutes itself.

Although the first concern of the police who entered the interior was
plainly to locate the injured persons and obtain emergency medical services,
the people in charge of the police evidently had a major concern relating
to protecting the crime scenes for the purpose of preserving evidence.

Because the emergency medical services personnel could not communicate
easily among themselves inside the building, they did not have the benefit
of proper coordination between their operation and the police operation.

The effect of the presence of police officers in civilian clothing,
with handguns, among the emergency medical services personnel inside the
building, and the uncontrolled rumour that there might be another suspect,
was that some personnel felt unsafe, and this did not enhance their ability
to provide the best possible services.

Ultimately, a systematic and organized search of the entire institution,
to ensure that there were no other victims, was undertaken very late.

2.5.3.2 Questions

- Is there a clearly defined procedure for transmitting requests for
action in a minimum of time?

- If so, do personnel at the dispatch centre have the training needed
for implementing it?

- Is it advisable, in the case of a well-known public building, to transmit
a request without specifying the municipal address?

- Are there policies in this respect?

- Are they followed?

- What are the precise criteria that govern the selection of a code when
a request is transmitted?

- Are the agents at the dispatch centre properly informed regarding the
importance of using the appropriate code?

- Are there clearly defined policies concerning the situations in which
the 9-1-1 centre may transfer a caller directly?

- Is there a directive dealing with a request for involvement by the
tactical squad?

- Who may make the decision?

- At what point may that person make that decision, and based on what
criteria?

- Are there cases in which the dispatch centre should notify the authorities
without delay?

- When the police respond to a call, should they have to inform dispatch
when they arrive on the scene?

- When dispatch is informed by the police that they have arrived on the
scene, should it not immediately inform the command post that has been
established on site, if one has been established?

- When a command post is established on the scene, should dispatch not
systematically inform all vehicles of this?

- Do the authorities regularly monitor how these directions are followed?

- What directives govern the duties of a police officer on the scene
of an ongoing armed attack where persons are potentially in danger?

- Are there pre-established intervention plans?

- What are the intervention protocols in ongoing armed attack cases where
persons are potentially in danger?

- How should leadership of the operation on site be ensured?

- How are the lines of authority established?

- What equipment is required and how is it ensured that it is immediately
available?

- Should a strategy designed both to neutralize the suspect and protect
that actual and potential victims not have been formulated quickly, without
waiting for the tactical squad to become involved?

- Did the people in charge of the police have the training, and have
adequate preparation, for quickly formulating and implementing that kind
of strategy?

- Are there permanent links in place between the security services in
public buildings and police forces, to plan intervention protocols, and
a degree of coordination, in advance?

- Could the École's security service not have been an important
source of information for a description of the scene and the situation
inside the building, and an estimate of the number of people who were
potentially in danger during the event?

- Is it an established practice to use the fire alarm to effect speedy
evacuation in the case of an armed assault or attack, or is it known to
be dangerous to do this, and if so, should the police and the security
services in public buildings not be informed of the procedure to follow
in order to avoid any ad hoc decisions?

- Is there a clearly defined procedure, as between Urgences-Santé
and the SPCUM, regarding situations that are both criminal and medical
in nature?

- If so, does that procedure provide for a process of exchanging information
in order to plan their respective actions?

- Are there joint protocols for prioritizing emergency medical services
to injured persons while also preserving crime scenes to the extent possible?

- On what basis is the decision made, and by whom, to authorize ambulance
workers to enter premises which have not already been secured?

- In addition to locating victims, should the police participate in the
process by which emergency medical services workers provide services?

- Should they participate in coordinating the operation when the victims
are in several different locations?

- Should they, when necessary, provide support for emergency medical
services workers to communicate among themselves?

- Should they ensure that emergency medical services workers are at all
times, and feel, safe?

2.5.4 Université de Montréal or École Polytechnique
security service

2.5.4.1 Observations

The École Polytechnique security service had little or no contact
with the police involved in the operation before they entered the building.

There is no strict procedure for whether or not to set off the fire
alarm in the event of an armed assault or attack.

2.5.4.1 Questions

- Did the Université de Montréal security service have
permanent connections with the SPCUM for the purpose of establishing protocols
for intervention and coordination?

- Does the Université de Montréal security service have
plans for its buildings that can be very speedily accessed by the police?

- Is the use of the fire alarm to effect speedy evacuation in the case
of an armed assault or attack, or the danger of using the fire alarm,
established practice for the Université de Montréal security
service, and should all security service employees not be informed of
whichever practice has been established?

2.5.5 General

Based on the study by the medical committee, it was established, to
a certainty, that none of the victims who died could have been saved by
medical treatment, having regard to the nature of their injuries, even
had emergency medical services responded more rapidly.

Obviously, the only question to be answered is this: having regard to
the brief time frame in which the entire event took place, would each
and every one of the victims who died have been shot, in any event, even
if the police had implemented a strategy that was formulated speedily
to neutralize the attacker?

It was not possible to answer that last question in the affirmative,
to a certainty, nor could the question regarding the strictly medical
component, having regard to the delays that occurred: the delay caused
when the request was transmitted by the 9-1-1 centre, the time taken by
the SPCUM to transmit the request over the air, the delay caused by the
provision of incomplete information to the vehicles regarding the exact
location of the event, and the time spent waiting for reinforcements because
of an inaccurate assessment of the resources already available.

2.6 CONCLUSIONS

As unfortunate as this event was, it was not an exceptional one from
the perspective of the emergency services. An armed attack by a single
person is, in itself, an event that the SPCUM must deal with on a regular
basis.

Nonetheless, we must consider the sixty (60) unused bullets that Marc
Lépine left at the scene when he decided to put an end to this
terrible episode, although he was in no danger: no police assault was
in progress or in any obvious state of preparation. Thank heaven, he decided
on his own that enough was enough.

The issue of firearms control has intentionally not been addressed.
With the unlimited ammunition and time that Marc Lépine had available
to him, he would probably have been able to achieve similar results even
with a conventional hunting weapon, which itself is readily accessible.
On the other hand, the importance of the questions raised in respect of
pre-hospital care and police emergency response are matters that are worthy
of our full attention.

The deficiencies identified in relation to the emergency response call
for us, in all good conscience, to give them serious thought, not so that
we can assign responsibility to anyone in particular, but so that we can
take corrective action to ensure that better protection is provided for
human life.

Some of the questions stated in the preceding section do not require
answers, since the answers are self-evident from the questions. Nonetheless,
this does not mean that it is not worth acting on them, even though no
formal recommendations are made.

There are numerous other questions, on the other hand, that it would
be neither wise nor fair to try to answer without first hearing all of
the people involved, particularly since the complexity of some elements
means that various experts would have to be heard, and this was not the
function of a Coroner's investigation.